On Cancer: Urologist John Mulhall Explains Strategies for Addressing Sexual Health Concerns for Men with Cancer

Experts at Memorial Sloan-Kettering understand that men may experience sexual difficulties and fertility problems as a result of their cancer or cancer treatment. In fact, our Male Sexual and Reproductive Medicine Program, which launched in 2009 as part of the Survivorship Initiative, is devoted entirely to addressing these issues.

In a recent interview, urologist and sexual medicine physician John Mulhall, director of the program, explained common concerns about male sexual health and offered advice for men and their partners.

What types of cancer might have an impact on a man’s sexual health?

The majority of patients who come to see me have received a diagnosis of prostate, testicular, bladder, or another urologic cancer, but we also see men with colorectal cancer and those who have undergone a bone marrow or stem cell transplant. There are quite a variety of patients who seek our help in any given week.

It's actually more the treatments and therapies used to fight cancer today that could cause men to experience some loss of sexual function during and after treatment. Radiation therapy, which damages erection tissue, and hormone therapy, which reduces testosterone levels, can have an impact on a man’s ability to be sexually aroused. And surgery in and around the pelvic region – a radical prostatectomy (removal of the prostate), cystectomy (removal of the bladder), or rectal surgery – might leave him with other short- and long-term health problems.

What are some of the more common sexual health concerns men express?

When men come to meet with me, they are most often concerned about or are already experiencing some level of erectile dysfunction, or ED – the ability to get and maintain a firm erection. ED is caused by damage to the erection nerves and arteries when the prostate gland is removed or during radiation therapy.

But increased stress levels play a role, too, and learning how to cope with this can be difficult for some. An increase in stress over time causes our brain to release adrenaline, the “fight or flight” hormone, and adrenaline is the most potent anti-erection chemical. So anything that increases adrenaline is a risk factor for sexual dysfunction, including a diagnosis of cancer.

Low libido, premature ejaculation, delayed orgasm, and sexual incontinence are other common concerns, so it’s important that men understand early on that there are methods and medications we have to help them. I tell my patients that they should always leave my office feeling optimistic, because there is nearly always something we can do for them.

What are the most common treatments for sexual dysfunction?

Treatment for ED usually involves an oral medication such as sildenafil citrate (Viagra^®), vardenafil HCI (Levitra^®), or tadalafil (Cialis^®). These medications are commonly prescribed.

After prostatectomy, patients might not respond to oral medication, so penile injections are commonly recommended in place of this. We believe that having an erection after treatment helps keep tissue healthy, but injection therapy is temporary and is used as a form of rehabilitation therapy. Generally, the injection is a mix of different medicines that works by relaxing the smooth muscle in the penis and opening the blood vessels causing an erection. Men learn to use the injection at home on their own after we review the treatment with them in the office. After a few weeks, most men can stop using the injections, and continue on oral medications and see positive results.

What does a typical appointment with you involve?

During an appointment, I talk with men about the problems they’re experiencing and how they are affected. I often refer to this as their “bother index.” Their bother index is connected to many things including whether they have a sexual partner, how sexual they are, and what their sexual activity level was before treatment. Most men who come to see me are motivated because they have decided they want help.

There are also many times when men invariably come to see me because they have psychological-based erection problems. Take for example a man diagnosed with testicular cancer. The stress of a diagnosis and having a testicle removed may in some ways cause a man to feel emasculated. And this in turn is connected to his ability to have an erection. Our sexual health team includes mental health professionals, social workers, and couples’ therapists, so counseling is available to every patient and his partner to help enhance communication and intimacy.

Who should a man speak with about his sexual health concerns? What advice do you have for men who are uncomfortable talking about this topic?

Men should speak with their doctor about any sexual health concerns they have prior to and during treatment. Part of my job is to educate and empower patients by encouraging them to take an active role in their healthcare. Sometimes it takes a few visits before a man works up the courage to say something. We can’t help you unless we understand the problem, so we need you to be your own best advocate. Not raising the issue is often a tremendous source of regret among men I meet.

At Memorial Sloan-Kettering, we are doing an excellent job of curing patients, but we are doing an even better job of addressing survivorship issues like loss of sexual function and fertility awareness. And I think we need to continue to empower patients to ask questions.

Should partners be part of this discussion as well?

Yes. I think that when men receive a diagnosis of cancer, their partners automatically become engaged, and having them present in these conversations can help. I often say that I am 10 percent psychologist because you cannot practice sexual medicine at the level we do and not have an understanding of couple dynamics.